Is a chest x-ray (CXR) required before using a nasojejunal (NJ) tube?

Chest X-ray Confirmation is Required Before Using a Nasojejunal Tube

A chest X-ray is absolutely necessary to confirm proper placement of a nasojejunal tube before initiating feeding to prevent potentially life-threatening complications. 1

Rationale for Mandatory X-ray Verification

• The American College of Radiology explicitly recommends X-ray confirmation after initial blind placement of any nasojejunal tube before feeding is initiated 1
• Misplacement can lead to serious complications including:
  • Pulmonary intubation
  • Pneumothorax
  • Incorrect small bowel positioning
  • Aspiration pneumonia

Specific X-ray Requirements

• The recommended radiographic study is a plain chest X-ray (anteroposterior view) that includes visualization of the upper abdomen 1
• This allows visualization of the entire course of the tube from insertion through the esophagus and into the small intestine 1
• In most cases, a single AP view is sufficient to determine nasojejunal tube position 2
• Two views (AP and lateral) should be reserved only for cases where the tube position cannot be definitively assessed on the AP view 2

Evidence Supporting X-ray Verification

• Between 2005-2010,45% of all cases of harm caused by misplaced nasogastric tubes reported by the National Patient Safety Agency were due to misinterpreted radiographs, highlighting the critical importance of proper verification 3
• In a study examining nasojejunal tube placement, researchers found that in 14.9% of patients, image quality was insufficient for conclusive visibility of tube positioning 4
• The Austrian Association for Clinical Microbiology and Infectious Diseases strongly recommends confirmation of correct tube position by X-ray before donor feces are installed in the upper GI tract 3

Factors Affecting X-ray Visibility

• Patient factors associated with poor tube visibility on X-ray include:
  • High body mass index
  • Male sex 4
• Technical factors improving visibility:
  • Presence of a guidewire inside the tube during X-ray imaging 4
  • Proper patient positioning

When Additional X-rays Are Required

• Reconfirmation by X-ray is necessary when:
  • There is clinical suspicion of tube displacement
  • After episodes of vomiting, retching, or coughing that might displace the tube 1
  • When feeding intolerance occurs

Alternative Verification Methods

While X-ray remains the gold standard, some alternative methods exist but have limitations:

• Electromagnetic guidance devices have shown 98% sensitivity and 100% specificity compared to X-ray 5
• However, these specialized devices are not universally available and still often require X-ray confirmation in clinical practice

Clinical Algorithm for Nasojejunal Tube Management

1. Insert nasojejunal tube using appropriate technique
2. Obtain chest X-ray (AP view including upper abdomen) before initiating any feeding
3. Have X-ray interpreted by trained personnel to confirm proper placement
4. Only after confirmation of correct position, initiate feeding
5. Monitor for signs of tube displacement (vomiting, respiratory distress, feeding intolerance)
6. Repeat X-ray if any concern for displacement occurs
7. Position patient with head elevated 30-45 degrees during feeding to reduce aspiration risk 1

In conclusion, while alternative methods for confirming tube placement exist, the chest X-ray remains the gold standard for verification of nasojejunal tube placement and is mandatory before initiating feeding to ensure patient safety and prevent potentially fatal complications.